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Cornea and External Disease Robert Cykiert, M.D

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Cornea and External Disease Robert Cykiert, M.D Cornea and External Disease Robert Cykiert, M.D. I. Basics papilla vascular response if giant, the differential includes atopy, vernal, GPC, prosthesis, suture follicles lymphatic response acute chronic EKC, pharygoconjunctival fever adult inclusion conjunctivitis medicamentosa (epinephrine, neosynephrine) toxic Parinaud's oculoglandular,syndrome r/o sarcoid HSV primary conjunctivitis r/o GPC, vernal conjunctivitis Newcastle's conjunctivitis with acute follicles, always check lid margin for HSV vesicles, ulcers membranes conjunctivitis ocular cicatricial pemphigoid erythema multiforme Stevens Johnson syndrome Srogrens syndrome atopy Symblepharon scieroderrna burns radiation burns trachoma EKC sarcoid drugs filaments exposure (keratoconjunctivitis sicca, neurotrophic, patching recurrent erosion) bullous keratopathy HSV meds superior limbic keratoconjunctivitis psoriasis aerosol keratitis diabetes mellitus radiation retained FB Thygeson's SPK ptosis Enlarged Corneal nerves MEN TIIb icthyosis Hanson's Kconus Refsums Fuchs corneal dystrophy old age failed PKP congenital glaucoma trauma neurofibromatosis MEN TIIb AD with thick corneal nerves, medullary thyroid cancer, pheochromocytoma, mucosal neuromas, and marfanoid habitus thickened lid margin with rostral lashes, thick lips, epibulbar neuromas cafe au lait spots, periungual, lingual neuromas often confused with NFI often die early from amyloid producing thyroid cancer in 10-20 year old with distant mets at dx thick nerves precede the cancer! corneal edema whenever epithelium disrupted, can stimulate iritis via reflex arc epithelial intracellular first intercellular with microbulla then subcellular with frank bulla stomal all extracellular factors imbibition pressure = IOP - swelling pressure (nl 50) fluid into cornea from IOP, gyclosoaminoglycans's fluid out of cornea by dehydration, pump IOP is inverse with swelling pressure with nl endothelium, high IOP-- epithelial edema with nl IOP, poor endothelium-- stromal edema rx mild muro 128, hair dryer, control IOP moderate soft CL, cycloplegia, PK, conjunctival flap Brown McClean syndrome peripheral edema in aphakic, pseudophakic with orange pigment on endothelium Stains Flouresecin staining when disruption of cell-cell junctions Rose Bengal stains with disruption of precorneal tear film cell death increases permeability to these dyes, but Rose Bengal can still be blocked with tears II. Lids/conjunctiva Congenital Epitarsus fold of conjunctiva on palpebral lid Osler Weber Rendu hereditary hemorrhagic telangiectasia AD, dilated blood vessels on palpebral conjunctiva in star/sunflower shape 1-3 mm, violacious, blanches, increased with age telangiectasia that bleed easily, rarely in retina and look like HTN or DM retinopatby problems with epistaxis and GI bleeding Congenital lymphedema XLR, AD, usually massive edema of legs dysplasia of lymphatics Medicamentosa Anaphylactic sulfonamides, bacitracin, anesthetic Allergic with eczema, SPK, red eye atropine, homatropine, aminoglycosides, antivirals Toxic often after 1 wk of use, especially keratoconjunctivitis sicca pts papilla, redness, SPK, no itch aminoglycosides, antiviral, preservative Follicular months to years later big follicles, pannus, SPK psuedotrachoma syndrome atropine, miotics, epinephrine, antivirals Conjunctivitis EKC adenovirus 8,9,13; can cause symblepharon EBV virus with mono can cause conjunctivitis, keratitis Newcastle disease virus with poultry exposure measles may have papillary corjunctivitis withwhite avascular spots ci caruncle/conjunctiva like Koplik spots in mouth Parinaud's OGS cat scratch children with cats, hx of scratch, sneeze, 2 wk latency, nodule in superior or inferior conjunctiva intense chemosis, injection, lymph nodes may appear up to 2 wks later systemic fever, malaise, maculopapultar rash DX: Hanger Rose test 90% sensitivity skin test Warthin Starry stain for bacilli RX: Doxycycline 100mg bid x 1 month tularemia lymph nodes, fever, chills, vomiting, pneumonia but ocular involved <5% necrotizing, ulcerating conjunctivitis, corneal ulcer, optic neuritis, dacryocystitis, panophthalmitis rabbit hunters, hx of tick bites with punched out lesion DX: with agglutination titers 1: 160 or higher in 2 weeks and peak in 4-8 wks RX: streptomycin, tetracycline sporotrichosis spherical elastic movable nodule, pink then purple then black and necrotic multiple subcutaneous nodules along lymphatics, multiple yellow nodules in conjunctiva sporotrichosis conjunctivitis seen in HI pts no systemic illness DX: culture on Sabouraud's RX: KI 1 ml/day Misc sarcoid leptothrix chancroid glanders Crohn's fungi lues TB lymphgranuloma veneream culture conjunctiva and scrape, blood clx if febrile, VDRL, FTA, PPD, viral titers, biopsy Reiters bilateral conjunctivitis, iridocyclitis, urethritis, polyarthritis fever, lymph nodes, pericarditis, pneumonitis, myocarditis think if chronic nonfollicular mucopurlent conjunctivitis SPK, corneal infiltrate, corneal neovascularization steroids, chlamydia/dysentery antibx? Floppy Lid SLK burning, no itch or discharge, symp worse than signs corridor hyperemia, velvety papilla upper tarsus +Rose Bengal, micropannus, fine SPK, filaments in 1/2 50% with mild thyroid dysfunction soft contact lens can also cause similar picture RX: scrape conjunctiva, pressure patch, soft contact lens, resect conjunctiva Thygeson's keratitis can often mimic SEI recurrent hx with quiet white eye bilateral raised heaped up epithelium with microcysts seen in retroillumination can mimic HSV coarse grey white lesions slightly elevated without flourescein stain dramatically responds to topical steroids often after 2 doses, taper in one wk some need chronic therapy due to rebound if steroids stopped molluscum SPK, pannus, follicles, pseudotrachoma Graft vs Host S1 conjunctiva hyperemia S2 chemosis, exudate S3 pseudomembranous S4 corneal epithelial slough higher stage correlates with increased severity of disease and mortality keratoconjunctivitis sicca most commonly, cicatticial lag, ectropion, persistent epithelial defects, iritis Chlamydia Trachoma superior pannus, SPK, corneal infiltrates, lid destruction and exposure are key elements tetracycline, erythromycin, or sulfonamides x 3 months S1 conjunctival follicles, cytoplasmic inclusion bodies S2 inflammation, increased corneal pannus S3 scaning flerbervs pits (lirnbal depressed necrotic follicles), Arlt's line S4 end stage Adult TRIC 5% with urethritis, 1-2 wk latency, meibomianitis, lid edema and redness follicular conjunctivitis, EKC-like SEI NO membranes superior pannus (not seen in EKC) doxycyline 100mg bid 10 days or erythromycin 250mg qid 3 wks, treat partner Newborn TRIC no follicles, more discharge, + pseudomembrane 4-12 days post partum, r/o GC Giemsa incl bodies 40%, 90% with + clamydiazime otitis, pneumonitis in 15%, recurrence 20% Erythromycin syrup 50mg/kg qid x 2 wks, treat mom LGV Parinaud's OGS, follicular conjunctivitis, conjunctival granuloma can have keratitis, corneal neomcularization, anterior uveitis Atopy RX allergy testing and environmental control compresses, pressure patch, air conditioning, pulse steroids vasoconstrictors, Acular, livostin, mast cell stabilizers immunosuppressives Hayfever rapid, lid swelling, chemosis (pale palpebral conjunctiva), itching, mucus, dellen pressure, rhinitis/asthma, episodic, may have no signs T1 hypersensitivity, elevated tear IgE, eosinophils in scraping in chronic cases Vernal (VKC) bilateral seasonal young (3-25 year old) in warmer climates, M>F FHx of atopic allergies self limited average 4- 1 0 years ITCH (worsens in evening, dust, lights, wind, rubbing), clear tears ropy discharge but lids don't get crusted or stick together unless bacterial superinfection GPC (may see a membrane form at the slit lamp), limbal involvement more in blacks (can be 360 degrees) Homer Trantas dots (clumps of degenerated eosinophils), clear elevated cysts SPK, flour dust of epithelium, intraepithelial cysts, shield ulcers usually upper cornea pseudoarcus, myopic astigmatism, associated with keratoconus, rare corneal neovascularization >2 eosinophils/hpf pathognomonic, increased tear histamine topical cyclosporine 2% qid can be used as alternative to steroids Atopic (AKC) M>F, teens to 40's, burns out by 40-50 year old, small papilla, milky edema, corneal neovascularization fix of atopic eczema (3% of pop), similar to venial findings but no seasonal changes symblepharon, foreshortening of inferior fornix, usually lower palpebral conjunctiva affected in severe cases bilateral cataracts (anterior subcapsular, or posterior polar) 10% of all atopic dermatitis associated with keratoconus, iritis, cataract RD from pars plana tears or ora dialysis (can have photoreceptor outer segments in anterior chamber which look like cells) increased serum IgE, few eosinophils in scraping and rarely free granules systemic antihistamines, nasal cromolyn, topical mast cell stabilizers, steroids and cream, doxycycline path increased T helper, macrophages, increased class If HLA similar to OCP and rosacea. more complex than simple mast cell allergic rx No BM deposition GPCofCL usually develops within first year of lens wear, but RGP can develop after years also seen in art eyes, sutuIres r/o VKC (no tear histamine, no free eosinophil granules, only 1/4 have eosinophils in scrapings early mucous discharge, mild itch with increased in severity, then pain with CL, blurred Va papilla may stain (sign of activity), whitish material on lens conjunctival injection or chemosis when severe, thick shem
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